1. WHO Regional Office for Europe HIV/TB Stakeholder Meeting Dr Hans Kluge Director Health Systems and Public Health Special Representative of the Regional Director on MXDR-TB Kiev, Ukraine 06 May 2014

2. WHO Regional Office for Europe

3. Removal of health system bottlenecks Service Delivery Population and individual level HS Governance HS Financing Resource generation (Human resources and technology) Core services Population level Individual level Population level Individual level Population level Individual level Population level Individual level Expected results Maternal and child health outcomes Cardiovascular health outcomes Tuberculosis Others From policy to action: HSS operational approach

4. WHO Regional Office for Europe Health systems in times of global economic crisis: an update, 17-18 April, Oslo, Norway Aligned health workforce Financial Protection

5. WHO Regional Office for Europe Policy responses to economic crisis in the EU

6. WHO Regional Office for Europe All people have access to needed health services (incl. prevention) of good quality Derived from World Health Report 2010, p.6 & World Health Assembly Resolution 58.33, 2005 What is Universal Health Coverage? The use of services does not expose any user (or family members) to undue financial hardship

7. WHO Regional Office for Europe Ten leading sources of inefficiency Ref: World Health Report 2010, Chapter 4 Medicines: under-use of generics and higher than necessary prices Medicines: use of sub-standard and counterfeit medicines Medicines: in appropriate and ineffective use Services: inappropriate hospital size (low use of infrastructure) Services: medical errors and sub- optimal quality of care Services: inappropriate hospital admissions and length of stay Services & products: oversupply and overuse of equipment, investigations and procedures Health workers: inappropriate or costly staff mix, unmotivated workers Interventions: inefficient mix / inappropriate level of strategies Leakages: waste, corruption, fraud

8. Continual focus on improving efficiency Eliminate ineffective and inappropriate services Improve rational use of medicines Allocate more to public health, primary and outpatient specialist care at the expense of hospital care Invest in infrastructure that is less costly to run – “invest to save” Cut the volume of least cost-effective services

9. WHO Regional Office for Europe Response to the crisis in Latvia Major cuts with concurrent structural reforms to health system –priority given to primary health care, coverage of essential medicines and outpatient specialist services –reduced hospital capacity and increased day care capacity –pharmaceutical reimbursement budget cut less than in-patient care budget Significant price reductions of pharmaceuticals –based on cost effectiveness evaluations and international comparisons –enabled treatment for an increasing number of patients for the same amount of money –WB funded Social Safety Net subsidy –provides 100% reimbursement of medicinal products for the poor

10. WHO Regional Office for Europe Major restructuring in Latvia: 35% reduction of expenditure on hospital in-patient care in two years 2010: 21 emergency care hospital,, 6 care hospitals, 12 specialized hospitals Number of patients in Day CareNumber of Home Care visits Data source: The Centre of Health Economics data review, Latvia

11. WHO Regional Office for Europe Shifting from hospital to ambulatory care of TB in the Republic of Moldova Facilitating factors 1.Higher costs of hospital care 2.Significant risks of re-infection and nosocomial transmission of MDR TB 3.Socio-economic impact related to patients’ long absence from the household Main obstacles 1.Resistance of medical personnel due to overburden and lack of proper incentives 2.Lack of experience of personnel working at PHC care level in monitoring TB treatment 3.Challenges in ensuring adequate nutrition and additional support in case of adverse effects Key success factors 1.Introducing bonuses for PHC personnel 2.Ensuring adequate nutritional and other support 3.Important role of NGOs and Community TB centres 4.Rapid diagnostic tools in place

12. WHO Regional Office for Europe 35 th Anniversary of Alma-Ata Declaration on PHC,6-7 November 2013

13. WHO Regional Office for Europe People-centeredness as a cornerstone of sustainable health systems People ServicesSettings Health Protection Health Promotion Disease Prevention Diagnosis Treatment Long-term care Rehabilitation Palliative care Public health Primary care Secondary care Specialist care Community, home & social care Pharmacies  The management and delivery of health services such that people receive a continuum of services through the different levels and sites of care within the health system, and according to their needs. “When they change my physician that means that something is going wrong. The first thing I thought was that I wasn’t doing so well anymore” “I have a disease that is called COPD (…) no one told me, I found out over time by myself, reading the package inserts of the drugs they prescribe me.” “We feel like there are people who really care about us here” [Patient receiving integrated HIV/injection drug services, Ukraine]

14. WHO Regional Office for Europe Sustainable Human Resources for Health BMJ, 314, 24May1997 Nurses/ Midwives

15. WHO Regional Office for Europe 120 000 lives and US$ 12 billion saved by implementing the Consolidated Action Plan The goal is to contain the spread of drug-resistant TB by: decreasing M/XDR-TB cases among previously treated cases by 20 percentage points; detecting 85% (or 225 000 ) M/XDR-TB patients; successfully treating at least 75% ( 127 000 ) of them.

16. WHO Regional Office for Europe HOW DOES IT FEEL TO TRANSFORM?

17. WHO Regional Office for Europe (HLC HIA Dec 2013) Harvard change mgt steps

18. WHO Regional Office for Europe Eight Steps to Transforming Your Organization Institutionalizing New Approaches Articulating the connections between the new behaviors and corporate success Developing the means to ensure leadership development and succession Forming A Powerful Guiding Coalition Assembling a group with enough power to lead the change effort Encouraging the group to work together as a team Creating a Vision Creating a vision to help direct the change effort Developing strategies for achieving that vision Communicating that Vision Using every vehicle possible to communicate the new vision and strategies Teaching new behaviors by the example of the guiding coalition Empowering Other to Act on the Vision Getting rid of obstacles to change Changing systems or structures that seriously undermine the vision Encouraging risk taking and nontraditional ideas, activities, and actions Planning for and Creating Short Term Wins Planning for visible performance improvements Creating those improvements Recognizing and rewarding employees involved in the improvement Consolidating Improvement and Producing Still More Change Using increased credibility to change systems, structures, and policies that don’t fit that vision Hiring, promoting, and developing employees who can implement the vision Reinvigorating the process with new changes, themes, and change agents Establishing a Sense of Urgency Examining market and competitive realities Identifying and discussing crises, potential crises, or major opportunities 1 2 3 4 5 6 7 8

19. WHO Regional Office for Europe http://www.euro.who.int/en/wh at-we-do/health-topics/Health- systems THANK YOU